Understanding the Potential Risk of VTE in Inflammatory Skin Diseases: Q&A With Dr Silverberg

Findings from a recent study showed patients with atopic dermatitis (AD), pemphigus, and pemphigoid may have an increased risk of venous thromboembolism (VTE).

Researchers arrived at their conclusion after analyzing data of 72,512,581 adults from the 2002-2012 Nationwide Inpatient Sample, which included 1,389,292 individuals with VTE. Using multivariable logistic regression models, they found hospitalizations for AD (adjusted odds ratio [OR] 1.22; 95% CI, 1.17-1.27), pemphigus (adjusted OR 1.96; 95% CI 1.68-2.28), and pemphigoid (adjusted OR 1.64; 95% CI 1.47-1.83) were associated with VTE. “These associations remained significant in virtually all patient subsets, including males and females, different age groups, and those with and without long-term corticosteroid use,” the researchers said.

AD, pemphigus, and pemphigoid were also found to be associated with both deep vein thrombosis and pulmonary embolus. VTE was associated with higher odds of hospitalization among patients with AD, pemphigus, and pemphigoid, as well as some subsets of patients with hidradenitis suppurativa (HS). However, psoriasis and HS were not consistently associated with VTE. In addition, VTE was associated with increased inpatient length of stay, cost of care, and mortality for all inflammatory skin diseases.

In an interview with The Dermatologist, corresponding author Jonathan Silverberg, MD, PhD, MPH, associate professor of dermatology at George Washington Medical School in Washington, DC, discussed these findings and its implications for clinical practice.

The Dermatologist: Why did you conduct this study?

Dr Silverberg: VTE is becoming a hot topic in chronic autoimmune and inflammatory skin diseases because it is a potential adverse event of some emerging therapies (eg, Janus kinase inhibitors).

Additionally, inflammatory skin diseases, such as AD, psoriasis, HS, and autoimmune blistering diseases, are chronic, debilitating diseases with dysregulation of various immune pathways, cutaneous and systemic inflammation, decreased physical activity, lower quality of life, and limitations on activities of daily living, all of which may increase the risk of VTE. However, no studies have previously examined whether chronic inflammatory skin diseases are associated with an increased likelihood of VTE.

The Dermatologist: You and your colleagues observed associations of AD, pemphigus, and pemphigoid with odds of hospitalization with VTE. How does this contribute to the existing literature on risk of vascular disease in patients with inflammatory skin diseases?

Dr Silverberg: The results indicate that these chronic inflammatory skin diseases should be included in the list of chronic diseases associated with increased VTE.

VTE was even increased in younger patients, who are typically at lower risk for VTE in the general population. We also found that long-term use of corticosteroids for the management of these disorders was particularly associated with increased odds of VTE.

Finally, we found that VTE was associated with prolonged hospitalization, increased costs of care, and mortality across all of the inflammatory skin diseases we studied.

The Dermatologist: For AD, specifically, how does this association with VTE add to the understanding of this skin disease and cardiovascular/vascular risk?

Dr Silverberg: Cardiovascular/vascular risk has been extensively studied in psoriasis, but less so in other chronic inflammatory skin diseases. Our results suggest that AD, autoimmune blistering disease, and perhaps other inflammatory skin diseases are also associated with increased cardiovascular/vascular risk. This may stem from risk factors that are common to these disorders, such as activation of specific immune pathways, the very common use of long-term corticosteroids, and/or sedentary lifestyle secondary to the impact of their disease on physical activity.

The Dermatologist: On the other hand, psoriasis and HS were not consistently associated with VTE in your study. Could you elaborate more on this finding?

Dr Silverberg: For HS in particular, the lack of association may in part be due to lower sample size. However, there may be differential effects of inflammatory skin diseases on VTE risk. In other words, not all inflammatory skin diseases have the same VTE risk. It is possible that increasing awareness of cardiovascular/vascular risk and availability of many highly efficacious nonsteroidal therapies in psoriasis may reduce the risk of VTE in real-world settings.

The Dermatologist: What research is still needed to address possible vascular risk factors in patients with inflammatory skin diseases?

Dr Silverberg: Future confirmatory studies are definitely warranted. In addition, studies are needed to determine the precise mechanisms of increased VTE risk in inflammatory skin disease.

The Dermatologist: What key takeaways would you like clinicians to have from your study?

Dr Silverberg: Clinicians should be aware of these associations for several reasons. First, patients with these disorders may benefit from increased screening for VTE. Second, there are simple recommendations that can be given to reduce VTE risk in clinical practice, including encouraging physical activity and smoking cessation. Third, clinicians should be cautious with respect to using medications that may further increase risk of VTE, such as systemic corticosteroids.

Reference

Shaheen MS, Silverberg JI. Association of inflammatory skin diseases with venous thromboembolism in US adults. Arch Dermatol Res. Published online July 8, 2020. doi:10.1007/s00403-020-02099-6